Anna Dixon: Do we need more generalists in our hospitals?

October 17, 2011

Medicine is becoming increasingly specialised: there are now almost 30 sub-specialties within the Royal College of Physicians alone. This is partly in response to the exponential rate at which scientific knowledge is produced – it is simply not possible to stay on top of the latest developments beyond a limited scope of practice.

Greater standardisation and new knowledge management tools could change this in future, but for now there are benefits to specialising. Once you have a diagnosis you are probably better off seeing someone who has expert knowledge and up-to-date skills in treating your condition. But is ever increasing specialisation in the best interests of patients?

I was part of a commission on the state of medical generalism, set up by the Royal College of General Practitioners, that considered just such questions. Its report, Guiding patients through complexity: Modern medical generalism, was published last week. The commission sets out one of the key principles of generalism as “seeing the person as a whole and in the context of their family and wider social environment.” While patient centred care is a feature of all good medical care, the particular value of a generalist is the ability to provide holistic care. Generalists have an important role in helping to co-ordinate input from a range of professionals and to ensure that patients’ wider needs are met.

Increasingly, patients within hospitals have multiple conditions that need the care of several specialists. The loss of generalists in hospitals means that patients often find themselves being shuttled from one specialist to the next, with no one taking overall responsibility for their care. There is also a real risk that important aspects of patients’ care are neglected – for example their mental health needs or basic requirements such as diet, hydration, and urinary function. These aspects of care are vital to patients’ recovery and mobility while in hospital, and to a timely discharge.

So do we need to bring back general physicians in hospitals? I would suggest that rather than bringing back the old model of general medicine we need to reinvent generalism in a hospital setting.

The commission was interested in the role of “hospitalists” in the US who actively manage patients while in hospital. Studies have shown that hospitalists reduce the length and average cost of a hospital stay, but do they also improve outcomes for patients? While a senior nurse could take on a role similar to a case manager or care co-ordinator within the hospital, extending the role of the general practitioner to follow their patients into hospital would be a more radical approach. This would only be possible with a radical rethink of the role of GPs and the skill mix of the primary care team.

However, generalism is not just something delivered by an individual. Given the growing complexity of some patients’ needs it might be more appropriate to develop multi-disciplinary teams, similar to virtual wards in the community but within the walls of hospitals, who case manage complex patients holistically during and immediately after discharge. These different models need to be tested and evaluated.

Patients need support and care from specialists and generalists regardless of where they are being cared for. We need to find ways of integrating specialist and generalist care so patients benefit from excellent clinical outcomes and holistic care.

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